CCS CCS ICD-10-CM Diagnosis Coding 3 — Questions and Answers
Question 1: Which ICD-10-CM instruction tells the coder to assign an additional code when more information is needed to fully describe the condition?
- Excludes1
- Code first
- Use additional code (Correct answer)
- Code also
Correct answer: Use additional code
'Use additional code' instructs the coder to assign a supplementary code to provide complete information about the condition.
Question 2: In ICD-10-CM, what is the 'default code' concept?
- A code automatically applied when no documentation exists
- The code listed next to a main term in the Index when no additional detail or subterm is provided (Correct answer)
- The first code in a code range used for billing
- A code that covers all unspecified conditions in a chapter
Correct answer: The code listed next to a main term in the Index when no additional detail or subterm is provided
The default code is the code listed next to a main term in the Alphabetic Index and is used when documentation does not specify additional detail.
Question 3: ICD-10-CM Chapter 21 (Z codes) is primarily used to report:
- Injuries and poisonings
- Factors influencing health status and contact with health services (Correct answer)
- Neoplasms and their morphology
- Mental and behavioral disorders
Correct answer: Factors influencing health status and contact with health services
Z codes (Chapter 21) capture reasons for encounters other than disease or injury, such as screenings, vaccinations, or status conditions.
Question 4: When a patient is admitted for a condition that is a complication of a prior procedure, the coder should:
- Code only the original condition that required the surgery
- Code the postprocedural complication as the principal diagnosis (Correct answer)
- Never code postprocedural complications
- Code only the procedure performed to treat the complication
Correct answer: Code the postprocedural complication as the principal diagnosis
A postprocedural complication code is sequenced as the principal diagnosis when it is the reason for the inpatient admission.
Question 5: What does the ICD-10-CM guideline 'code to the highest degree of specificity' mean?
- Always use the highest numeric code available
- Assign the most specific code available that is supported by documentation (Correct answer)
- Use combination codes whenever possible regardless of documentation
- Code every condition listed in the medical record
Correct answer: Assign the most specific code available that is supported by documentation
Coding to the highest degree of specificity means selecting the most detailed code supported by medical record documentation rather than a general or unspecified code.
Question 6: In ICD-10-CM, when coding drug-induced conditions, the coder must:
- Code only the condition caused by the drug
- Code the condition first, then use an additional code from T36-T50 to identify the drug (Correct answer)
- Code only the drug code from T36-T50
- Query the physician before assigning any drug-related code
Correct answer: Code the condition first, then use an additional code from T36-T50 to identify the drug
Drug-induced conditions require coding the manifestation first followed by a T-code from T36-T50 identifying the causative drug.
CCS CCS ICD-10-CM Diagnosis Coding 3
Which ICD-10-CM instruction tells the coder to assign an additional code when more information is needed to fully describe the condition?